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After you are treated by a provider, a billing statement is sent to the insurance company. Typically, a claims approver (sometimes it is handled electronically) will review the submitted claim and determine if it is covered, and how much of the claim will be paid by the insurer.
That amount is paid and any balance is now the responsibility of you...the insured. Of course, hopefully, it is a small amount! Our job, as brokers, is to help you find plans that keep your obligation of the bill as low as possible.
Agent Owner, Gilmore Insurance Services, Marysville, Washington State
How does a health insurance claim work? Let's follow a claim. First the billing is created in the doctor's office where staff submits a claim for payment to an insurance company. This could be done anywhere from that day or later that month, depending on the office. I have known of providers who have sent collection notices before they've even gotten around to billing.
When the claim arrives at the insurance company it goes straight to the claims departement where the informaion is entered into the computers. Basically the claims person gets the bill, data entries the necessary information and hits enter. From that point on, most claims are untouched by human hands.
The claim information goes into the computer where it is compared to the coverage the insured has. From that a payment and explaination of benefits page are created and sent on their ways.
When I use the term untouched by human hands I mean not everything processed is checked to see if the parameters (plan design) are correct. Usually, only billings above a certain size are rechecked for accuracy. Years ago the threshold was 20,000 got a second look by a human for accuracy. Companies leave it up to the insured to find any small errors and call in for corrections. The cost of double checking every claim would be astronomical.
Regional Marketing Director, Capital Choice Financial Group,
At the time of treatment, the medical facility will file your claim for you to the provider that you have. Just present your insurance card to the office person and they will keep it on file. You will then receive statements with the amount that was paid and what you, the patient owes the facility. Not hard as long as there are people doing their jobs.
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That amount is paid and any balance is now the responsibility of you...the insured. Of course, hopefully, it is a small amount! Our job, as brokers, is to help you find plans that keep your obligation of the bill as low as possible.
When the claim arrives at the insurance company it goes straight to the claims departement where the informaion is entered into the computers. Basically the claims person gets the bill, data entries the necessary information and hits enter. From that point on, most claims are untouched by human hands.
The claim information goes into the computer where it is compared to the coverage the insured has. From that a payment and explaination of benefits page are created and sent on their ways.
When I use the term untouched by human hands I mean not everything processed is checked to see if the parameters (plan design) are correct. Usually, only billings above a certain size are rechecked for accuracy. Years ago the threshold was 20,000 got a second look by a human for accuracy. Companies leave it up to the insured to find any small errors and call in for corrections. The cost of double checking every claim would be astronomical.